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It's 3 in the morning and Vonzie Barnett's pager is ringing. The pager has 12 audible settings. Barnett has the pager set on "the most irritating sound it will make," so he won't sleep through any calls.

The call is from LifeGift's communications center. There's a potential organ donor at St. Luke's Episcopal Hospital in Houston. This usually means someone has a devastating neurological injury such as trauma to the head, intracranial bleeding or an anoxic injury.

Barnett, RN, a certified procurement transplant coordinator, swings his feet out of bed and sits up. He is the manager of LifeGift's organ recovery services. His job is to set in motion the chain of events that will connect someone waiting to receive an organ, tissue, cornea or bone transplant with an unknown donor.

In Southeast Texas, nearly 100 hospitals are required to call LifeGift, the regional organ procurement organization, when a patient meets national guidelines as a potential organ or tissue donor. Most of the country is divided into statewide organ procurement organizations. Texas is one of a handful of states that has three regional organ procurement organizations because of the large number of hospitals in the state.

Chain reaction
Less than five minutes have elapsed. Barnett calls the hospital and speaks to a nurse. An ER patient potentially meets the criteria to be an organ donor.

Barnett asks if the patient is on a ventilator to determine if will he have time to get to the hospital to make an on-site assessment.

Because the patient has a brain injury and is on a ventilator, Barnett tells the nurse that he's on his way. His goal is to arrive at the hospital within an hour of notification. If patients do not have a brain injury or are not being ventilated, they cannot be organ donors. However, they may be potential tissue donors.

In that case, Barnett will give the information to the LifeGift tissue department for follow-up.

At the other end of the phone is Candy Davies, RN, an ER staff nurse at St. Luke's. Because of extensive in-servicing from organ procurement organizations, nurses in many hospitals are aware when one of their patients meets the criteria to be a potential organ donor, Davies said.

Assessment often begins when a patient is en route to the hospital. The EMT personnel will ask family members if the person has an underlying disease process and clinical history that might exclude him or her from being a potential donor.

When the patient hits the emergency room door, CPR is usually in progress. Davies asks if there are written directives. If the patient dies, LifeGift will be notified immediately.

"Many times a family member will verbalize his wishes and we pass this information along to LifeGift when we make the call," Davies said.

"If a family member is adamant that he does not wish his relative to be a donor, we notify LifeGift anyway. Sometimes, a coordinator will still want to come out and talk to the family. In my 26 years at St. Luke's, I've never known LifeGift not to honor the family's denial."

Davies talks to family members during a code to keep them updated. After an unsuccessful code, she goes with the ER physician, who speaks with the family to explain what procedures were done. She stays behind to ask if the family is willing to consider organ donation.

"I make it very much an open-ended question," Davies said. "I start off by asking if the family is aware of the program called LifeGift. Then I ask, 'What can you tell me about your understanding of LifeGift?' Then, 'Have you or your family member discussed making a donation to the LifeGift organization?' "

In broaching the subject of organ donation, Davies said the most important thing is to talk with the family, not at them. Be at eye level. Watch their body language to see if they are comfortable with the discussion. "Their face tells you everything," she said.

Beating the clock
Davies said she doesn't push organ donation onto a family. She introduces organ donation as an option.

Meanwhile, the clock is ticking. Minutes count. Barnett throws on a pair of scrubs and is out the door within 15 minutes.

He has been working as a transplant coordinator for seven years. To qualify for the job, most organ donor coordinators have at least three years of ICU or ER experience. Barnett said that to be able to manage the process, a nurse must have the critical-thinking skills that come out of ICU or ER nursing experience.

Once he arrives at the hospital, Barnett will comprehensively assess the patient's potential to be an organ donor. He introduces himself to the ER nurse and begins by reading the patient's chart.

"I'm looking for what initially brought the patient into the hospital, their previous medical history, the hospital course and what their prognosis is," Barnett said. "I'm trying to establish what their current organ function is."

Barnett looks at the latest lab work to assess liver, kidney and pancreas function. He would like to see normal lab values in those areas. He reads ABGs to determine lung function and any cardiac studies to determine heart function. Simply being on a ventilator is not an indication of patient respiratory failure. In trauma, for example, patients often are put on ventilators to protect their airway or as a result of neurological insult.

"The perfect donor will have an isolated head injury," Barnett said. "None of their other organ systems will have been affected by this head injury."

Barnett frequently comes across this kind of patient in the Houston area. The city has two level-one trauma centers and an air ambulance service. That means a significant number of head trauma patients due to motor vehicle accidents, gunshot wounds and CVAs.

It's now been 1½ hours since the initial phone call. Barnett has determined that this particular patient is suitable to be an organ donor-with a big "if" factor; that is, the patient must be pronounced brain dead.

As defined by the Harvard criteria, brain death is "the complete and irreversible cessation of all brain function including those originating in the brainstem." In practical terms, a physician must initiate testing for brain death.

Because Barnett is in a busy urban teaching hospital ICU, an attending trauma physician is nearby at this early hour. She quickly writes an order for a cerebral blood flow study. Done at the bedside, this diagnostic test confirms her clinical determination of brain death.

While the test is being done, Barnett assesses the patient's family to determine who is the legal next of kin. That's the person who will need to give consent for organ donation.

"That information is rarely on the patient chart," Barnett said. "Trauma patients frequently come in through the ER as unknowns. Sometimes, they don't have any identification. Even when they do, there's no information about the next of kin.

"At that point, I try to determine who that next of kin is and where they are. If I'm lucky, the police will have informed the family of the incident and the family will have arrived by the time I get there."

Once he identifies the legal next of kin, Barnett visits with them-not to bring up the issue of possible organ donation, but to provide the family with help or any information they might need at that moment.

"I'm establishing myself to the family as a medical professional who is knowledgeable about the family member's condition and is able to provide them with information and support. They've just had a devastating trauma in their lives. I'm able to help them through this difficult period. Whether they donate or not, I'm doing my job if I'm able to help the family."

While Barnett talks with the family, the confirmation of brain death has been made. The attending physician will give that information to the family. It's now been five hours since the initial phone call.

At an appropriate time after the family is informed about the diagnosis of brain death, Barnett returns to speak about organ donation.

Barnett initially confirms whether the family understands that the diagnosis of brain death means the patient is dead. Most patients' families do not understand that brain death means death, Barnett said.

"They've just been at the patient's bedside," Barnett explained. "They've seen the heartbeat and the blood pressure on the monitors. They've witnessed the ventilator breathing for the patient and saw the chest moving up and down. The family associates those things with the hope that the patient will survive. And here's the physician telling them the patient is brain dead. And I'm reinforcing that.

"Unless they can get to the point where they understand and are comfortable with the definition of brain death, it is unlikely they will consent to donate."

LifeGift obtains consent from about 65 percent of the families they approach. The national average is a little more than 50 percent.

It's been seven hours since Barnett first received the phone call. He now approaches the family to ask for consent for organ donation.

"If this family say yes, seven lives could be saved," Barnett said. "There are more than 77,000 people nationwide on various transplant waiting lists. If they say no, at least I know I've done the best I can for that family and for those people waiting for transplants," he said.

It's now about 10 a.m. Marlene Norman, RN, heart transplant department coordinator at St. Luke's Episcopal Hospital, is in her office when her pager beeps. Norman works the recipient side of the organ recovery process.

"I hear from LifeGift any time of the day or night when they have a potential donor," she said.

Gift of life
As soon as Barnett has a signed consent, he beeps Norman on her pager. When she calls back, Barnett will give her the donor's age, height, weight, vital signs, blood type, sex, labs, when they came in, how they died, when they were pronounced and what kind and strength of IV medicines they were on.

Because Norman deals specifically with heart transplants, she pays close attention to the IV drips. For example, she said, epinephrine can be hard on the heart, so she looks closely at someone who has been on high-strength epinephrine for more than 24 hours.

She also pays close attention to the echocardiograph looking for a good ejection fraction, normal valves, normal wall motion and any signs of coronary artery disease.

After the call from Barnett, Norman calls her transplant cardiologist to discuss the donor. They rule out obvious factors such as if the donor had a questionable past social or medical history or if the echocardiograph is marginal.

"Sometimes, we'll turn a donor down because the heart size doesn't fit the criteria for our specific patients," Norman said.

If they decide it's a good match, Norman then calls her director of cardiovascular transplant surgery. The whole process must be accomplished quickly because LifeGift needs an answer within one hour.

If it's a go, Norman tells Barnett they have a patient ready to receive the heart. Barnett gives Norman the timing, how long it will take to harvest the organs and total travel time.

The donor will go to the hospital's OR where surgeons will harvest a variety of organs for other waiting recipients. Norman's goal is to estimate what time the heart will arrive at her OR.

She has a list of people she needs to notify, including the OR, the surgical team, anesthesia, the blood bank and, finally, the recipient. "I'm the one who calls the patient. That's the fun part of my job," Norman said.

The recipient must arrive at the hospital within two hours of her call. That's not usually a problem, Norman said, because most people waiting for a transplant have been on an active waiting list for six to 18 months.

Still, when that phone call goes out, the immediate patient reaction is disbelief, Norman said. After so much waiting and anxiety, after so many things coming together, the moment has finally arrived for someone awaiting a new organ.